Prenatal Intake Form Client Prenatal Intake Form Todays Date:(Required) MM slash DD slash YYYY First Name:(Required)Last Name:(Required)Due DateDoctor/Midwife Name:(Required)Doctor/Midwife Phone:(Required)Birthing Facility Type (Eg: Hospital, Home birth, etc.)(Required)Number of Children & Ages(Required)Pre-pregnancy Weight:(Required)Current Weight:(Required)Pre-pregnancy Blood Pressure:(Required)Current Blood Pressure:(Required)Emergency Contact Name:(Required)Relationship:(Required)Phone:(Required)Any history of problems with this or previous pregnancies?(Required) No Yes If yes, please explain:Are you currently experiencing or have a history of any of the following?: (Please mark all that apply. This information is confidential and may be important to your therapy.) Bloody discharge Sudden rapid weight gain Visual disturbances Excessive hunger and thirst Increased urination in second trimester Persistent, severe back pain, unaffected by position change Continual abdominal pains Increased blood pressure Severe nausea and vomiting Persistent and severe headaches Please elaborate if you selected any of the above conditions:Primary reason for receiving massage therapy:(Required)Are there any other concerns that we may need to know about before you receive massage therapy?CAPTCHA
